Health Services Research最新文献_第10页

The Impact of Increased Medicaid Eligibility During Pregnancy on Medicaid Utilization and Gestational Age 怀孕期间增加医疗补助资格对医疗补助利用和胎龄的影响。

IF 3.2 2区医学 Q2 HEALTH CARE SCIENCES & SERVICES

Health Services Research

Pub Date : 2025-09-14 DOI: 10.1111/1475-6773.70037

Nicolas P. Goldstein Novick, Peter J. Veazie, Elaine L. Hill, Eva K. Pressman, Peter G. Szilagyi, Timothy D. Nelin, Scott A. Lorch

Objective

To assess the impact of increased Medicaid income eligibility during pregnancy on payment source for prenatal care and birth and on gestational age at birth (GAb).

Study Setting and Design

We performed a quasi-experimental, difference-in-differences study comparing two increases in Medicaid income eligibility during pregnancy to two control states with data from 2007 to 2010: (Dyad 1) Ohio (expanded from 150% to 200% of the Federal Poverty level [FPL]) versus Pennsylvania and (Dyad 2) Wisconsin (185% to 250% FPL) versus Michigan. We performed multinomial logistic regression to assess the impact of increased Medicaid eligibility on the following key outcome variables: payment source for prenatal care and birth and GAb.

Data Sources and Analytic Sample

We utilized CDC Pregnancy Risk Assessment Monitoring System (PRAMS) data (2007–2010) and limited analysis to singleton, in-state live births. After re-weighting for PRAMS survey design, our analytical sample represented about 540,000 births.

Principal Findings

In the higher-income Wisconsin-Michigan dyad, increased Medicaid eligibility during pregnancy significantly increased exclusive Medicaid coverage for prenatal care (7.0%, 95% CI 2.9% to 11.1%) and birth (8.3%, 4.3% to 12.4%). Simultaneously, private insurance coverage dropped for prenatal care (−4.0%, −7.7% to −0.3%) and birth (−3.7%, −7.2% to −0.2%) while self-payment decreased only for birth (−1.8%, −3.5% to −0.2%). In the lower-income Ohio-Pennsylvania dyad, the only statistically significant effects on payment source were decreases in the likelihood of a payment source of other for prenatal care (−3.3%, −6.2% to −0.3%) and birth (−4.7%, −7.9% to −1.6%). There were no statistically significant effects on GAb across both dyads.

Conclusions

Increased Medicaid eligibility during pregnancy for individuals of higher income seems to improve utilization of exclusive Medicaid with diminished uninsurance but also less private insurance after accounting for indicators of socioeconomic advantage but has no clear impact on GAb. Medicaid policy should balance reducing uninsurance with directing scarce resources to high-risk individuals.

目的：评估孕期医疗补助收入资格增加对产前护理和分娩支付来源以及出生胎龄（GAb）的影响。研究设置和设计：我们进行了一项准实验，差异中差异研究，比较了两个对照州在怀孕期间医疗补助收入资格的两次增加，数据来自2007年至2010年：（Dyad 1）俄亥俄州（从联邦贫困水平[FPL]的150%扩大到200%）与宾夕法尼亚州和（Dyad 2）威斯康星州（从185%扩大到250% FPL）与密歇根州。我们使用多项逻辑回归来评估增加医疗补助资格对以下关键结果变量的影响：产前护理和分娩的支付来源和GAb。数据来源和分析样本：我们使用疾病预防控制中心妊娠风险评估监测系统（PRAMS）数据（2007-2010年），并对单胎和州内活产婴儿进行有限分析。在对PRAMS调查设计重新加权后，我们的分析样本代表了大约54万名新生儿。主要发现：在高收入的威斯康辛-密歇根双组中，怀孕期间医疗补助资格的增加显著增加了产前护理（7.0%,95% CI 2.9%至11.1%）和分娩（8.3%，4.3%至12.4%）的独家医疗补助覆盖率。与此同时，私人保险的产前护理（-4.0%,-7.7%,-0.3%）和生育（-3.7%,-7.2%,-0.2%）的保险覆盖率有所下降，而自付保险的保险覆盖率只有生育（-1.8%,-3.5%,-0.2%）有所下降。在收入较低的俄亥俄州和宾夕法尼亚州，对支付来源的唯一统计显著影响是产前护理（-3.3%,-6.2%至-0.3%）和分娩（-4.7%,-7.9%至-1.6%）的其他支付来源的可能性降低。在两对夫妇中，GAb没有统计学上的显著影响。结论：考虑到社会经济优势指标后，高收入个体怀孕期间医疗补助资格的增加似乎提高了独家医疗补助的利用率，减少了不保险，但也减少了私人保险，但对GAb没有明显影响。医疗补助政策应该在减少无保险和将稀缺资源导向高风险人群之间取得平衡。

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引用次数: 0

Bundled Payment Programs and Changes in Practice Patterns and Episode Spending in Major Gastrointestinal Surgery 胃肠外科手术的捆绑支付方案和实践模式的变化。

IF 3.2 2区医学 Q2 HEALTH CARE SCIENCES & SERVICES

Health Services Research

Pub Date : 2025-09-14 DOI: 10.1111/1475-6773.70046

Cody Lendon Mullens, David Schwartzman, Samantha L. Savitch, Jyothi R. Thumma, Scott E. Regenbogen, Justin B. Dimick, Edward C. Norton, Kyle H. Sheetz

Objective

To evaluate the association between enrollment in the Bundled Payments for Care Improvement –Advanced (BPCI-A) program and changes in utilization of minimally invasive surgery and 90-day episode spending for patients undergoing major gastrointestinal surgery.

Study Setting and Design

We compared hospitals that voluntarily enrolled in BPCI-A to control hospitals that did not participate. We used entropy balancing to reweight controls to match the BPCI-A cohort based on observable patient and hospital characteristics. We then used a difference-in-differences approach to estimate the association between surgical approach and 90-day episode payments.

Data Sources and Analytic Sample

We used Medicare claims and American Hospital Association data between 2013 and 2021 to evaluate whether hospital enrollment in the BPCI-A program was associated with changes in 90-day episode spending and utilization of minimally invasive surgical approaches. Using entropy balancing, we reweighted the control group to achieve covariate balance with beneficiaries who obtained care at BPCI-A program hospitals. We performed a difference-in-differences analysis using multivariable linear and generalized linear models, adjusting for patient demographics, comorbidities, and hospital characteristics, with standard errors clustered at the hospital-year level to evaluate these outcomes.

Principal Findings

Changes in 90-day episode payments at BPCI-A program hospitals versus non-program hospitals were not significantly different (−$172, 95% CI: −$1104 to $760). In comparing trends at BPCI-A program and control hospitals, we identified no significant differences in utilization trends for minimally invasive surgical approaches (relative risk difference: −0.003, 95% CI: −0.10 to 0.04). The similarity in utilization trends between BPCI-A program and control hospitals was observed in the context of increasing overall utilization of MIS approaches from 40.3 to 38.4 to 43.9 to 42.9 during the study period, respectively.

Conclusions

We found no evidence that hospitals participating in BPCI-A's major bowel surgery episodes led to differences in episode spending or utilization of minimally invasive surgical approaches.

目的：评估纳入BPCI-A计划与大胃肠手术患者微创手术使用率和90天发作花费的变化之间的关系。研究设置和设计：我们比较了自愿参加BPCI-A的医院和未参加的对照医院。我们根据观察到的患者和医院特征，使用熵平衡来重新加权对照，以匹配BPCI-A队列。然后，我们使用差异中的差异方法来估计手术入路与90天发作付款之间的关系。数据来源和分析样本：我们使用2013年至2021年间的医疗保险索赔和美国医院协会的数据来评估BPCI-A项目的住院登记是否与90天住院费用的变化和微创手术入路的使用有关。利用熵平衡，我们对对照组进行了重新加权，以实现在BPCI-A项目医院接受治疗的受益人的协变量平衡。我们使用多变量线性和广义线性模型进行了差异中差异分析，调整了患者人口统计学、合并症和医院特征，并在医院年水平上聚集了标准误差，以评估这些结果。主要发现：BPCI-A项目医院与非项目医院的90天发作付款变化无显著差异（- 172美元，95% CI: - 1104美元至760美元）。在比较BPCI-A项目和对照医院的趋势时，我们发现微创手术入路的使用趋势没有显著差异（相对风险差异：-0.003,95% CI: -0.10至0.04）。在研究期间，BPCI-A项目和对照医院的MIS方法的总体利用率分别从40.3提高到38.4，从43.9提高到42.9，在这种情况下，利用趋势相似。结论：我们没有发现任何证据表明参与BPCI-A大肠手术的医院会导致发作花费或微创手术入路的使用差异。

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引用次数: 0

Association of School-Based Health Center Availability With Child Mental Health Outcomes 校本保健中心可用性与儿童心理健康结果的关系。

IF 3.2 2区医学 Q2 HEALTH CARE SCIENCES & SERVICES

Health Services Research

Pub Date : 2025-09-11 DOI: 10.1111/1475-6773.70042

Carrie E. Fry, Mason Shero, Melinda B. Buntin, Carolyn J. Heinrich

Objective

To estimate changes in student mental health outcomes after the adoption of a school-based health center (SBHC).

Study Setting/Design

Using a retrospective, quasi-experimental design, this study compared changes in mental health diagnoses and healthcare utilization among students in school districts that adopted an SBHC to students in districts that did not adopt an SBHC, before and after adoption. A stacked difference-in-differences estimator was used to address the staggered adoption of SBHCs and the potential for heterogeneous treatment effects. Health conditions (measured via diagnosis codes) and health care use (measured via procedure codes and place-of-service codes) were obtained from Medicaid inpatient, outpatient, physician, and pharmacy claims.

Data Sources and Analytic Sample

Information on the availability of SBHCs was obtained via census of 142 of Tennessee's 147 public school districts. Using secondary data from administrative health and education records, we probabilistically linked Tennessee students enrolled in Medicaid to public-school records from 2006 to 2021. We linked approximately 70% of students enrolled in a Tennessee public school to Medicaid records.

Principal Findings

We identified 41 districts with an SBHC between 2007 and 2019. After the adoption of an SBHC, districts with an SBHC had a 0.5 (95% CI: −0.9, −0.2) percentage point decline in the proportion of students with any mental health diagnosis, which corresponds to a 6.6% relative decline. This was driven by a decrease in the diagnosis of depression, anxiety, and attention deficit and hyperactivity disorder (ADHD). We also found a significant increase in outpatient mental health care visits and a decrease in emergency department visits for mental health conditions after the adoption of an SBHC.

Conclusions

SBHCs are one mechanism through which the mental health needs of school-aged children are met. Timely and adequate resources are needed to ensure SBHCs can sustain their services in this time of need.

目的：评估采用校本健康中心（shbhc）后学生心理健康结果的变化。研究设置/设计：本研究采用回顾性、准实验设计，比较了采用儿童心理健康规范的学区学生与未采用儿童心理健康规范的学区学生在实施前后心理健康诊断和医疗保健利用方面的变化。采用了一种叠置差中差估计器来解决shbhcs的交错采用和异质性治疗效果的潜在问题。健康状况（通过诊断代码测量）和医疗保健使用（通过程序代码和服务地点代码测量）从医疗补助住院病人、门诊病人、医生和药房索赔中获得。数据来源和分析样本：通过对田纳西州147个公立学区中的142个学区进行普查，获得了关于shbhcs可用性的信息。利用来自行政卫生和教育记录的二手数据，我们将2006年至2021年参加医疗补助计划的田纳西州学生与公立学校的记录概率地联系起来。我们将田纳西州一所公立学校约70%的学生与医疗补助记录联系起来。主要发现：在2007年至2019年期间，我们确定了41个地区拥有shbhc。在采用精神健康健康中心后，有精神健康健康中心的地区，有任何精神健康诊断的学生比例下降了0.5个百分点（95%置信区间：-0.9,-0.2），相当于相对下降了6.6%。这是由于抑郁症、焦虑症、注意力缺陷和多动障碍（ADHD）的诊断减少所致。我们还发现，采用shbhc后，门诊精神卫生保健就诊人数显著增加，急诊精神卫生状况就诊人数减少。结论：儿童心理健康中心是满足学龄儿童心理健康需求的一种机制。需要及时和充足的资源，以确保家庭健康服务中心能够在这个需要的时候继续提供服务。

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引用次数: 0

Racial Disparities in Medication Adherence and the Patient-Provider Relationship: Does Racial/Ethnic Concordance Matter? 药物依从性和医患关系中的种族差异：种族/民族一致性重要吗？

IF 3.2 2区医学 Q2 HEALTH CARE SCIENCES & SERVICES

Health Services Research

Pub Date : 2025-09-10 DOI: 10.1111/1475-6773.70040

Alyson Ma, Jason Campbell, Alison Sanchez, Steven Sumner, Mindy Ma

<div> <section> <h3> Objective</h3> <p>To examine the impact of patient-provider racial/ethnic concordance on adherence to a prescribed medication regimen in marginalized populations with a focus on health issues related to hypertension, heart condition/disease, elevated cholesterol, and diabetes.</p> </section> <section> <h3> Study Setting and Design</h3> <p>Applying the Andersen-Newman Behavioral Model of Health Service Use, we estimate multivariate linear models to analyze the number of prescriptions filled by patients within a calendar year using publicly available data from the Medical Expenditure Panel Survey (MEPS), a set of large-scale surveys of families and individuals, their medical providers, and employers across the United States.</p> </section> <section> <h3> Data Sources and Analytic Sample</h3> <p>Data from MEPS on patient race/ethnicity and provider race/ethnicity were collected from survey years 2007 to 2017 as well as data to control for demographic, socioeconomic, and health factors. Our sample includes 238,355 observations, including 46.1% White respondents, 27.1% Hispanic respondents, 19.3% Black respondents, and 7.5% Asian respondents. There are 52,069 (about 22%) cases of patient-provider concordance.</p> </section> <section> <h3> Principal Findings</h3> <p>We find a positive association between adherence to a prescribed medication regime and racial/ethnic patient-provider concordance. Patients identifying as non-White fill their prescriptions approximately three times less often than White patients. Relative to White patients in racial/ethnic concordance with their providers, there is an increase in the number of filled prescriptions for Black patients in racial/ethnic concordance with their providers (coef = 0.715; <i>p</i> = 0.02). For patients with hypertension, being in a racial/ethnic concordant relationship with their providers increases the number of prescription refills (White: coef = 1.884, <i>p</i> < 0.001; Black: coef = 2.360, <i>p</i> < 0.001; Hispanic: 1.925, <i>p</i> < 0.001; Asian: 1.461, <i>p</i> = 0.003). The number of prescription refills also increases for White (coef = 1.665, <i>p</i> < 0.001), Hispanic (coef = 3.469, <i>p</i> < 0.001), and Asian (3.796, <i>p</i> < 0.001) patients with heart condition/disease and in racial/ethnic concordance with their providers.</p> </section> <section> <h3> Conclusions</h3> <p>The results provide evidence supporting that patients in racial/ethnic concordant relationships with their providers have a greater predisposition to medication adherence even after controlling for enabling, need, and other predisposing factors, particularly for patients with certain chronic medical diseases. Health policy implications are discussed.</p> </section>

目的：研究边缘化人群中患者-提供者种族/民族一致性对依从处方药物方案的影响，重点关注与高血压、心脏病/疾病、高胆固醇和糖尿病相关的健康问题。研究设置和设计：应用安德森-纽曼健康服务使用行为模型，我们使用医疗支出小组调查（MEPS）的公开数据估计多元线性模型来分析患者在一个日历年内填写的处方数量，这是一组对美国各地的家庭和个人，他们的医疗提供者和雇主的大规模调查。数据来源和分析样本：MEPS收集了2007年至2017年调查期间患者种族/民族和提供者种族/民族的数据，以及控制人口、社会经济和健康因素的数据。我们的样本包括238,355个观察结果，其中白人受访者占46.1%，西班牙裔受访者占27.1%，黑人受访者占19.3%，亚洲受访者占7.5%。有52,069例（约22%）患者-提供者的一致性。主要发现：我们发现在遵守处方药物制度和种族/民族患者-提供者一致性之间存在正相关。被认定为非白人的患者配药的频率大约是白人患者的三分之一。相对于与提供者种族/民族一致的白人患者，与提供者种族/民族一致的黑人患者的配药数量增加（coef = 0.715; p = 0.02）。对于高血压患者而言，与医疗服务提供者的种族/民族和谐关系增加了再处方次数（White: coef = 1.884, p）。结论：研究结果证明，即使在控制了使能、需要和其他易感因素后，与医疗服务提供者的种族/民族和谐关系的患者在药物依从性方面有更大的倾向，特别是对于患有某些慢性疾病的患者。讨论了卫生政策的影响。

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引用次数: 0

Hospitals in Some States Under Report Medicaid Discharge Counts in Cost Report Data 一些州的医院报告医疗补助出院数在成本报告数据。

IF 3.2 2区医学 Q2 HEALTH CARE SCIENCES & SERVICES

Health Services Research

Pub Date : 2025-09-08 DOI: 10.1111/1475-6773.70043

Kelsey Chalmers, Omkar Waghmare, Valérie Gopinath, Vikas Saini

Objective

To investigate discrepancies in Medicaid enrollees' hospital discharges reported in two data sources widely used in health services research: the CMS Hospital Cost Report Information System (HCRIS) and the T-MSIS Analytic Files (TAF).

Study Setting and Design

This is a descriptive study comparing inpatient discharges reported in the two data sets. We included inpatient admissions at general hospitals in 2020–2021.

Data Sources and Analytic Sample

We used HCRIS data covering reporting periods starting in 2020 and ending sometime in 2021 (this varied by hospital) and extracted the reported total and Health Maintenance Organization (HMO) funded Medicaid discharges and patient days. We used the 2020 and 2021 TAF inpatient files and included inpatient admissions within each hospital's HCRIS reporting period, and calculated discharges for each hospital.

Principal Findings

There were 25 states where some hospitals had higher TAF discharge counts than HCRIS, and these same hospitals had inconsistent reporting of HMO-funded Medicaid discharges and patient days in HCRIS. This included California, New York, and Texas. There were 20 states with similar values reported in both HCRIS and TAF, and 9 of these were in states with < 5% of their enrolled Medicaid population in a comprehensive managed care plan.

Conclusions

The discrepancies between HCRIS and TAF data indicate that HCRIS may not reliably capture hospital discharge volumes for Medicaid patients, particularly those funded by managed care. These inconsistencies can misinform policy decisions and evaluations of hospital performance. Policymakers and researchers should exercise caution when using HCRIS data for Medicaid discharge counts and consider supplementing it with TAF or other sources.

目的：探讨在医疗服务研究中广泛使用的两种数据来源：CMS医院成本报告信息系统（HCRIS）和T-MSIS分析文件（TAF）中医疗补助参保人出院报告的差异。研究设置和设计：这是一项描述性研究，比较两个数据集报告的住院病人出院情况。我们纳入了2020-2021年综合医院的住院患者。数据来源和分析样本：我们使用的HCRIS数据涵盖了从2020年开始到2021年结束的报告期（这因医院而异），并提取了报告的总数和健康维护组织（HMO）资助的医疗补助出院和患者天数。我们使用了2020年和2021年TAF住院患者档案，并纳入了每家医院HCRIS报告期内的住院患者，并计算了每家医院的出院率。主要发现：有25个州的一些医院的TAF出院数高于HCRIS，而这些医院在HCRIS中报告的hmo资助的医疗补助出院数和病人天数不一致。这包括加利福尼亚、纽约和德克萨斯。有20个州报告的HCRIS和TAF值相似，其中9个州的结论是：HCRIS和TAF数据之间的差异表明HCRIS可能不能可靠地反映医疗补助患者的出院量，特别是那些由管理式医疗资助的患者。这些不一致可能会误导政策决定和对医院绩效的评估。政策制定者和研究人员在使用HCRIS数据进行医疗补助出院计数时应谨慎行事，并考虑用TAF或其他来源补充。

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引用次数: 0

A Critical Examination of the Certified Community Behavioral Health Clinic Model: Provider Perceptions and Themes 认证社区行为健康诊所模式的关键检查：提供者的看法和主题。

IF 3.2 2区医学 Q2 HEALTH CARE SCIENCES & SERVICES

Health Services Research

Pub Date : 2025-09-07 DOI: 10.1111/1475-6773.70041

Tugba Olgac, Emma McCann, Michelle Riske-Morris, David L. Hussey

Objective

To explore the experiences of providers from two community behavioral health agencies involved in the implementation of Certified Community Behavioral Health Clinics (CCBHCs).

Study Setting and Design

This qualitative study was conducted as part of a larger evaluation of CCBHC implementation outcomes in two community-based behavioral health agencies. Ninety-one participants, including case managers, counselors, care coordinators, and leadership teams from both agencies, participated in focus group discussions to share their experiences regarding the implementation of the CCBHC model within their organizations.

Data Sources and Analytic Sample

Three rounds of focus group discussions were held between 2021 and 2023. A total of 24 focus groups were audio-recorded and transcribed by one of the researchers. Qualitative data was analyzed by two researchers using the systematic text condensation method.

Principal Findings

Six themes emerged from the focus groups reflecting both positive impacts and implementation challenges. Providers reported the implementation of CCBHCs improved service accessibility and effective care coordination; however, staff noted difficulties connecting clients with essential community resources, including housing and transportation. Both agencies underwent significant organizational transformation, although communication strategies varied by agency size. Finally, providers observed improved communication, client benefits (e.g., reduced hospitalizations), and positive organizational change. Despite these successes, agencies expressed significant concerns about long-term program viability due to reliance on temporary grant funding.

Conclusion

The CCBHC model of integrated care has expanded significantly in recent years. Most participants reported a positive cultural shift within their agencies following CCBHC implementation. However, limited community resources continue to restrict agencies' ability to address clients' basic needs. Since the CCBHC model was implemented through temporary grant funding, sustainability remains a concern. Both issues underscore the need for policies that increase the availability of community resources and ensure the long-term viability of CCBHCs.

目的：探讨两家社区行为健康机构的服务提供者参与实施认证社区行为健康诊所（CCBHCs）的经验。研究设置和设计：本定性研究是对两家社区行为健康机构CCBHC实施结果进行更大评估的一部分。91名参与者，包括来自两个机构的病例管理人员、咨询师、护理协调员和领导团队，参加了焦点小组讨论，分享了他们在组织内实施CCBHC模式的经验。数据来源和分析样本：在2021年至2023年期间举行了三轮焦点小组讨论。一名研究人员对24个焦点小组进行了录音和转录。两位研究者采用系统的文本浓缩方法对定性数据进行分析。主要发现：焦点小组提出了六个主题，反映了积极影响和执行方面的挑战。提供者报告说，CCBHCs的实施改善了服务可及性和有效的护理协调；然而，工作人员指出，很难将客户与基本的社区资源联系起来，包括住房和交通。这两个机构都经历了重大的组织变革，尽管传播策略因机构规模而异。最后，提供者观察到沟通得到改善，客户受益（例如，住院次数减少），以及积极的组织变革。尽管取得了这些成功，但由于依赖临时拨款资金，各机构对项目的长期可行性表示严重担忧。结论：CCBHC的综合护理模式近年来有了明显的扩展。大多数参与者报告说，在实施ccbhch后，其机构内的文化发生了积极的转变。然而，有限的社区资源继续限制了机构解决客户基本需求的能力。由于CCBHC模式是通过临时拨款实施的，可持续性仍然是一个问题。这两个问题都强调需要制定政策，增加社区资源的可用性，并确保社区卫生保健中心的长期生存能力。

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引用次数: 0

The Impact of Team-Based Ordering Workflows on Ambulatory Physician EHR Time, Order Volume, and Visit Volume 基于团队的订购工作流程对门诊医生EHR时间、订单量和访问量的影响。

IF 3.2 2区医学 Q2 HEALTH CARE SCIENCES & SERVICES

Health Services Research

Pub Date : 2025-09-06 DOI: 10.1111/1475-6773.70038

Nate C. Apathy, Alice S. Yan, A. Jay Holmgren

Objective

To analyze national rates of team-based ordering and evaluate changes in key outcomes following adoption.

Study Setting and Design

We conducted an observational pre-post intervention-comparison study of 249,463 ambulatory physicians across 401 organizations using the Epic EHR. Our intervention was the adoption of team-based ordering, measured as the proportion of orders involving team support. Outcomes include active ordering time, overall EHR time, order volume, and visit volume among adopter physicians.

Data Sources and Analytic Sample

We analyzed the distribution and trends in team-based ordering rates from Epic Signal (September 2019–March 2022). We used multi-variable regression in a difference-in-differences framework to evaluate changes in our outcomes among 115 adopters of team-based ordering and 3115 non-adopters. We defined adopters as physicians who demonstrated a one-time shift from 0% of orders to a consistent non-zero share of orders, and non-adopters as those who demonstrated constant 0% teamwork for at least 18 months.

Principal Findings

Across our study period, 26.2% of orders involved team support, with surgical specialists averaging greater team-based ordering (43.1%) than primary care (22.2%) and medical specialists (23.0%). There was no association between team-based ordering adoption and time spent ordering (−0.13 min/visit, 95% CI: [−0.48 to 0.22]) or total EHR time (−1.42 min/visit, [−3.79 to 0.95]). Adoption was associated with a 26.8% relative increase in order volume (0.47 orders/visit, [0.14–0.80]) and a 22.3% relative increase in visit volume (6.50 visits/week [2.81–10.19]).

Conclusions

Team-based ordering rates are relatively low, and new adoption of team-based ordering was not associated with physicians' time spent ordering or in the EHR overall. Teamwork may facilitate substantial increases in both order and visit volume, but a greater level of team-based ordering may be required to realize EHR time savings.

目的：分析全国团队订货率，评价采用团队订货后主要结果的变化。研究设置和设计：我们使用Epic EHR对401个组织的249,463名门诊医生进行了干预前后的观察性比较研究。我们的干预措施是采用基于团队的订单，以涉及团队支持的订单比例来衡量。结果包括主动订购时间、总体电子病历时间、订单量和采用者的访问量。数据来源和分析样本：我们分析了Epic Signal（2019年9月- 2022年3月）基于团队的订购率的分布和趋势。我们在差异中的差异框架中使用多变量回归来评估115名采用团队为基础的排序和3115名非采用团队为基础的排序的结果变化。我们将采用者定义为一次性从0%的订单份额转变为始终如一的非零订单份额的医生，而非采用者定义为至少18个月内始终如一的0%团队合作的医生。主要发现：在我们的研究期间，26.2%的订单涉及团队支持，外科专家平均以团队为基础的订单（43.1%）高于初级保健（22.2%）和医学专家（23.0%）。基于团队的订购采用与订购时间（-0.13分钟/次，95% CI:[-0.48至0.22]）或总电子病历时间（-1.42分钟/次，[-3.79至0.95]）之间没有关联。采用与订单量相对增长26.8%（0.47单/次，[0.14-0.80]）和访问量相对增长22.3%（6.50次/周[2.81-10.19]）相关。结论：以团队为基础的订制率相对较低，新的采用团队为基础的订制与医生花费的订制时间或电子病历总体无关。团队合作可能会促进订单和访问量的大幅增加，但可能需要更大程度的基于团队的订单来实现EHR时间节省。

{"title":"The Impact of Team-Based Ordering Workflows on Ambulatory Physician EHR Time, Order Volume, and Visit Volume","authors":"Nate C. Apathy, Alice S. Yan, A. Jay Holmgren","doi":"10.1111/1475-6773.70038","DOIUrl":"10.1111/1475-6773.70038","url":null,"abstract":"<div>\u0000 <section>\u0000 <h3> Objective</h3>\u0000 <p>To analyze national rates of team-based ordering and evaluate changes in key outcomes following adoption.</p>\u0000 </section>\u0000 <section>\u0000 <h3> Study Setting and Design</h3>\u0000 <p>We conducted an observational pre-post intervention-comparison study of 249,463 ambulatory physicians across 401 organizations using the Epic EHR. Our intervention was the adoption of team-based ordering, measured as the proportion of orders involving team support. Outcomes include active ordering time, overall EHR time, order volume, and visit volume among adopter physicians.</p>\u0000 </section>\u0000 <section>\u0000 <h3> Data Sources and Analytic Sample</h3>\u0000 <p>We analyzed the distribution and trends in team-based ordering rates from Epic Signal (September 2019–March 2022). We used multi-variable regression in a difference-in-differences framework to evaluate changes in our outcomes among 115 adopters of team-based ordering and 3115 non-adopters. We defined adopters as physicians who demonstrated a one-time shift from 0% of orders to a consistent non-zero share of orders, and non-adopters as those who demonstrated constant 0% teamwork for at least 18 months.</p>\u0000 </section>\u0000 <section>\u0000 <h3> Principal Findings</h3>\u0000 <p>Across our study period, 26.2% of orders involved team support, with surgical specialists averaging greater team-based ordering (43.1%) than primary care (22.2%) and medical specialists (23.0%). There was no association between team-based ordering adoption and time spent ordering (−0.13 min/visit, 95% CI: [−0.48 to 0.22]) or total EHR time (−1.42 min/visit, [−3.79 to 0.95]). Adoption was associated with a 26.8% relative increase in order volume (0.47 orders/visit, [0.14–0.80]) and a 22.3% relative increase in visit volume (6.50 visits/week [2.81–10.19]).</p>\u0000 </section>\u0000 <section>\u0000 <h3> Conclusions</h3>\u0000 <p>Team-based ordering rates are relatively low, and new adoption of team-based ordering was not associated with physicians' time spent ordering or in the EHR overall. Teamwork may facilitate substantial increases in both order and visit volume, but a greater level of team-based ordering may be required to realize EHR time savings.</p>\u0000 </section>\u0000 </div>","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":"61 1","pages":""},"PeriodicalIF":3.2,"publicationDate":"2025-09-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12857449/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145006839","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Clinician Specialties, Quality Score and Shared Savings Receipt in Accountable Care Organizations 临床医生专业，质量评分和共享储蓄收据在负责任的医疗机构。

IF 3.2 2区医学 Q2 HEALTH CARE SCIENCES & SERVICES

Health Services Research

Pub Date : 2025-09-04 DOI: 10.1111/1475-6773.70033

Mariétou H. Ouayogodé, Xiaodan Liang

Objective

To assess the relationship between the changing Accountable Care Organizations-ACO workforce and ACOs' shared savings earnings and quality performance.

Data Sources

Medicare Shared Savings Program-MSSP provider-level research identifiable files, performance year financial and quality report public use files, and National Physician Compare data (2013–2021).

Study Setting and Design

We characterized 865 MSSPs, separately pre- (2013–2019) and post-pandemic (2020–2021) according to the percentage of primary care physicians (PCPs), non-physicians, specialists, and other specialty, financial risk model, assigned Medicare beneficiary demographics, clinical risk factors, and provider supply by specialty within the MSSP's primary service state, (total and per-capita) shared savings earnings/losses owed and quality score. Longitudinal ordinary least-squares regressions with random effects were estimated to assess the association between MSSP provider specialty mix and annual (1) per-capita shared savings/losses and (2) quality score, controlling for risk model, beneficiary characteristics, provider supply, and year factors. We also compared outcomes across MSSPs, 32 Pioneers and 62 Next Generation-NGACOs.

Principal Findings

PCPs represented 33.9% of MSSP's workforce, on average. Higher percentages of PCPs and non-physicians were associated with higher per-capita earned shared savings and quality scores among MSSPs. A 1-percentage-point (ppt) increase in PCPs and non-physicians was associated with higher per-capita shared savings of $2.25 (p < 0.01) and $1.82 (p = 0.03), respectively, pre-COVID, and $2.73 (p < 0.01) and $1.81 (p = 0.14) post-COVID. We estimated increases in quality scores among MSSPs of ~0.1 ppt with a 1 ppt increase in PCPs, non-physicians, and specialists only pre-pandemic. No statistically significant relationships were estimated between provider specialty mix and performance measures in Pioneers and NGACOs.

Conclusions

Higher percentages of PCPs and non-physicians were associated with higher per-capita shared savings earnings and quality scores among MSSPs. As new federal initiatives continue to unfold, value-based payment models increasing incentives for primary care should be monitored to determine their ability to further improve care efficiency.

目的：评估责任护理组织- aco员工队伍变化与aco共享储蓄收入和质量绩效之间的关系。数据来源：医疗保险共享储蓄计划- mssp提供者级别的研究可识别文件，绩效年度财务和质量报告公共使用文件，以及国家医师比较数据（2013-2021）。研究设置和设计：我们根据初级保健医生（pcp）、非医生、专家和其他专业的百分比、财务风险模型、指定的医疗保险受益人人口统计数据、临床风险因素和MSSP主要服务状态下专科的提供者供应、（总和人均）共享储蓄收益/损失和质量评分，分别对865家MSSP进行了特征描述（2013-2019年）和大流行后（2020-2021年）。采用随机效应的纵向普通最小二乘回归来评估MSSP提供者专业组合与年度(1)人均共享储蓄/损失和(2)质量评分之间的关系，控制风险模型、受益人特征、提供者供应和年份因素。我们还比较了mssp、32家先锋和62家下一代ngaco的结果。主要发现：pcp平均占MSSP员工总数的33.9%。在mssp中，pcp和非医生的比例越高，人均收入共享储蓄和质量得分越高。pcp和非医生比例每增加1个百分点（ppt），人均共享储蓄就会增加2.25美元(p)。结论：pcp和非医生比例越高，mssp的人均共享储蓄收入和质量得分就越高。随着新的联邦倡议不断展开，基于价值的支付模式增加了对初级保健的激励，应加以监测，以确定其进一步提高护理效率的能力。

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引用次数: 0

Clinician Specialization in Skilled Nursing Facility Practice and Post-Acute Outcomes of Patients With Dementia 临床医生专业化的熟练护理设施实践和急性痴呆患者的预后。

IF 3.2 2区医学 Q2 HEALTH CARE SCIENCES & SERVICES

Health Services Research

Pub Date : 2025-08-31 DOI: 10.1111/1475-6773.70035

Seiyoun Kim, Hye-Young Jung, Derek Lake, Rebecca T. Brown, Rachel M. Werner, Jason Karlawish, Kira Ryskina

Objective

To evaluate the effects of physician and advanced practitioner specialization in skilled nursing facility (SNF)-based practice (SNFists) on the outcomes of patients with Alzheimer's disease and related dementias (ADRD) admitted to SNF for post-acute care.

Study Setting and Design

Taking advantage of the natural experiment provided by the growth of SNFists, we conducted a within-SNF difference-in-differences analysis with cross-temporal matching. Our primary outcome was functional improvement at SNF discharge, measured using a validated activities of daily living (ADL) score. Secondary outcomes included unplanned rehospitalization, emergency department (ED) visits, observational stays within 30 days of SNF admission, successful discharge to the community, SNF length of stay, admission into long-term nursing home care within 6 months of SNF discharge, and 30- and 60-day Medicare payments for professional and facility services.

Data Sources and Analytic Sample

Medicare facility and professional claims and Nursing Home Minimum Data Set (MDS) data from 2012 and 2019 were used. The study sample included 338,574 community-dwelling fee-for-service Medicare beneficiaries with ADRD, age 65 or older, discharged from an acute care hospital to one of the 5196 SNFs that experienced an increase in patients treated by SNFists.

Principal Findings

We did not observe an association between SNFist care and patient post-acute care outcomes or costs.

Conclusions

Specialization in SNF-based practice among physicians and advanced practitioners alone may not be an effective strategy to improve post-acute care outcomes or reduce costs to Medicare for patients with ADRD.

目的：评价医师和高级执业医师专业化在熟练护理机构（SNF）为基础的实践（SNFists）对入住SNF进行急性后护理的阿尔茨海默病及相关痴呆（ADRD）患者预后的影响。研究设置与设计：利用snfist生长提供的自然实验条件，我们进行了跨时间匹配的snf内差异中差异分析。我们的主要结局是SNF出院时的功能改善，使用经过验证的日常生活活动（ADL）评分进行测量。次要结果包括意外再住院、急诊就诊、SNF入院后30天内的观察住院、成功出院、SNF住院时间、SNF出院后6个月内进入长期养老院护理、30天和60天的医疗保险支付专业和设施服务。数据来源和分析样本：使用2012年和2019年的医疗保险设施和专业索赔以及养老院最低数据集（MDS）数据。研究样本包括338,574名社区居住的ADRD的按服务收费的医疗保险受益人，年龄在65岁或以上，从急症护理医院出院到5196个snf之一，SNFists治疗的患者增加。主要发现：我们没有观察到snfirst护理与患者急性后护理结果或成本之间的关联。结论：医生和高级从业人员在snf基础上的实践专业化可能不是改善急性后护理结果或降低ADRD患者医疗保险成本的有效策略。

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引用次数: 0

Effects of Continuous Medicaid Coverage in 2020–2023 on Children's Health Insurance Coverage, Access to Care, Health Services Use by Type, and Health Status 2020-2023年持续医疗补助覆盖对儿童健康保险覆盖、获得护理、按类型使用健康服务和健康状况的影响。

IF 3.2 2区医学 Q2 HEALTH CARE SCIENCES & SERVICES

Health Services Research

Pub Date : 2025-08-31 DOI: 10.1111/1475-6773.70034

Wei Lyu, George L. Wehby

Objective

To examine the effects of continuous Medicaid coverage in 2020–2023 under the Families First Coronavirus Response Act (FFCRA) on children's health insurance coverage, access to care, likelihood of using healthcare services by type, and health status.

Study Setting and Design

A difference-in-differences event study compares outcomes pre and post FFCRA between states without pre-FFCRA continuity provisions (treatment group) and those that required 12-month continuous coverage (control group).

Data Sources and Analytical Sample

The main sample includes 122,901–126,117 children (depending on outcome) aged 1–17 years with family income below 300% of federal poverty level from the 2016–2023 National Survey of Children's Health.

Primary Findings

After FFCRA, public coverage increased in treatment states in 2020, 2021, and 2022 by 4.1 (95% CI: 0.004, 8.3), 4.7 (95% CI, 0.4, 9.0), and 5.4 (95% CI: 2.0, 8.7) percentage points, respectively, relative to control states. Privately purchased coverage declined in 2020 by 3.5 (95% CI: −5.3, −1.7) percentage points. The likelihood of having a usual place for sick care increased by 3.6 (95% CI: 0.5, 6.8) percentage points in 2021, and the likelihood of unmet care needs decreased by 1.7 (95% CI: −2.8, −0.7) and 2.4 (95% CI: −3.8, −1.0) percentage points in 2021 and 2022. The likelihood of excellent/very good health increased by 2.5 (95% CI: 0.4, 4.5), 3.8 (95% CI: 0.7, 6.8), and 2.7 (95% CI: 0.4, 5.0) percentage points in 2020, 2021, and 2023, respectively. There were no changes in the likelihood of medical, preventive, mental health, specialist, and emergency department visits and hospital admissions.

Conclusions

Medicaid continuity under the FFCRA increased the children's public coverage rate. Despite potential switching from private coverage, there is evidence for reductions in unmet care needs and improved health status. Findings provide insights into potential effects of recent federal requirements that all states provide 12-month Medicaid continuity for children.

目的：研究根据《家庭第一冠状病毒应对法案》（FFCRA）， 2020-2023年持续医疗补助覆盖对儿童健康保险覆盖、获得医疗服务、按类型使用医疗服务的可能性和健康状况的影响。研究设置和设计：一项差异中的差异事件研究比较了没有FFCRA之前连续性规定的州（治疗组）和需要12个月连续覆盖的州（对照组）在FFCRA之前和之后的结果。数据来源和分析样本：主要样本包括2016-2023年全国儿童健康调查中家庭收入低于联邦贫困线300%的1-17岁儿童122,901-126,117名儿童（取决于结果）。主要发现：FFCRA后，与对照组相比，治疗州在2020年、2021年和2022年的公共覆盖率分别增加了4.1 （95% CI: 0.004, 8.3）、4.7 （95% CI: 0.4, 9.0）和5.4 （95% CI: 2.0, 8.7）个百分点。到2020年，私人购买的覆盖率下降了3.5个百分点（95%置信区间：-5.3,-1.7）。在2021年，拥有通常的生病护理场所的可能性增加了3.6个百分点（95% CI: 0.5, 6.8），在2021年和2022年，未满足护理需求的可能性降低了1.7个百分点（95% CI: -2.8, -0.7）和2.4个百分点（95% CI: -3.8, -1.0）。在2020年、2021年和2023年，极好/非常好健康的可能性分别增加了2.5个百分点（95% CI: 0.4、4.5）、3.8个百分点（95% CI: 0.7、6.8）和2.7个百分点（95% CI: 0.4、5.0）。在医疗、预防、心理健康、专科和急诊科就诊和住院的可能性方面没有变化。结论：FFCRA下的医疗补助连续性提高了儿童的公共覆盖率。尽管有可能从私人保险转向，但有证据表明，未满足的护理需求有所减少，健康状况有所改善。最近，联邦政府要求所有州为儿童提供12个月的医疗补助计划，这一发现为潜在影响提供了见解。

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